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Addressing Knowledge Gaps in the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: a Review of Recent Coronary Artery Calcium Literature

  • Coronary Heart Disease (S. Virani and S. Naderi, Section Editors)
  • Published:
Current Atherosclerosis Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Coronary artery calcium (CAC) has been proposed as an integrator of information from traditionally measured, non-traditionally measured, and unmeasured risk factors for coronary atherosclerosis. The 2013 American College of Cardiology/American Heart Association Guideline on the Assessment of Cardiovascular Risk identified several knowledge gaps regarding CAC, including radiation risks, cost-effectiveness, and improving discrimination and reclassification of estimated risk over the Pooled Cohort Equations in the ACC/AHA Atherosclerotic Cardiovascular Disease Estimator. In this review, we focus on recent CAC literature addressing these knowledge gaps. We further highlight the potential for CAC to enrich future randomized controlled trials.

Recent Findings

The use of CAC allows for personalization of cardiovascular risk despite the presence or absence of traditional risk factors across many demographics. Avenues to reduce radiation exposure associated with CAC scanning include increasing the interval between scans for those with CAC scores of zero and estimating CAC from non-cardiac gated CT scans. While limited studies have suggested cost-effectiveness in cardiac risk assessment with the incorporation of CAC in screening algorithms, several studies have demonstrated the ability of CAC to identify non-traditional risk factors that may be used to expand cardiovascular risk personalization in other high-risk populations.

Summary

Literature from the past 2 years further supports CAC as a strong marker to personalize cardiac risk assessment. While multiple potential avenues to reduce radiation are available and cost-effectiveness analyses are encouraging, further studies are necessary to clarify patient selection for CAC scanning given the interplay between CAC and other imaging modalities in risk personalization algorithms.

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Abbreviations

CAC:

Coronary artery calcium

ACC:

American College of Cardiology

AHA:

American Heart Association

ASCVD:

Atherosclerotic cardiovascular disease

CCTA:

Coronary computed tomography angiography

CVD:

Cardiovascular disease

MESA:

Multi-ethnic Study of Atherosclerosis

CRP:

C-reactive protein

MPI:

Myocardial perfusion imaging

ABI:

Ankle-brachial index

PCSK9:

Proprotein convertase subtilisin/kexin type 9

SPECT:

Single photon emission computed tomography

HR:

Hazard ratio

OR:

Odds ratio

RR:

Relative risk

DLR:

Diagnostic likelihood ratio

AUC:

Area under the curve

ROS:

Receiver operating statistics

EFV:

Epicardial fat volume

COPD:

Chronic obstructive pulmonary disease

ED:

Erectile dysfunction

NAFLD:

Non-alcoholic fatty liver disease

SLE:

Systemic lupus erythematous

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Authors and Affiliations

  1. Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, 600 N Wolfe St, Carnegie 591, Baltimore, MD, 21287, USA

    Vasanth Sathiyakumar, Roger S. Blumenthal, Khurram Nasir & Seth S. Martin

  2. Center for Healthcare Advancement and Outcomes & Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA

    Khurram Nasir

  3. Department of Epidemiology, Robert Stempel College of Public Health, Miami, FL, USA

    Khurram Nasir

  4. Department of Medicine, Herbert Wertheim College of Medicine, Miami, FL, USA

    Khurram Nasir

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  1. Vasanth Sathiyakumar
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  2. Roger S. Blumenthal
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  3. Khurram Nasir
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  4. Seth S. Martin
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Correspondence to Seth S. Martin.

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Conflict of Interest

Vasanth Sathiyakumar and Roger S. Blumenthal declare that they have no conflict of interest.

Khurram Nasir declares personal fees from the Advisory Board for Quest Diagnostics and from Consultant for Regeneronon.

Seth S. Martin declares grant support from PJ Schafer Cardiovascular Research Fund, American Heart Association, Aetna Foundation, CASCADE FH, Google, Apple, and the David and June Trone Family Foundation. He also declares personal fees from Abbott Nutrition, Pressed Juicery, Quest Diagnostics, Sanofi/Regeneron, Amgen, and Pew Research Center. Dr. Martin is also listed as a co-inventor on a pending patent filed by Johns Hopkins University for the novel method of low-density lipoprotein cholesterol estimation.

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This article is part of the Topical Collection on Coronary Heart Disease

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Sathiyakumar, V., Blumenthal, R.S., Nasir, K. et al. Addressing Knowledge Gaps in the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: a Review of Recent Coronary Artery Calcium Literature. Curr Atheroscler Rep 19, 7 (2017). https://doi.org/10.1007/s11883-017-0643-4

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